Cervical Debranching for Endovascular Arch

Repair:

Results, Tips and Tricks

ES Debus, Ch Vermeulen, A Larena, S Wipper, N Tsilimparis, T Kölbel

Department for Vascular Medicine

German Aortic Center Hamburg

University Heart Center Hamburg, Germany

Disclosure

Speaker name:

Univ.-Prof. Eike Sebastian Debus, FEBS, FEBVS

.................................................................................

I have no conflicts of interest to this lecture

Gold Standard for the Arch

Surgery for the aortic arch:

– Open repair

– Elephant trunk

– Frozen elephant trunk

Mortality rates 5-15%

Stroke: 4-12%

Sundt et al. 2008; Ann Thorac Surg 86:787-96

Minakawa et al. 2010; Ann Thorac Surg 90:72-7

Tsagakis et al. 2013 Ann Cardiothorac Surg 2:612-20

• n=38 (27 Zone 0, 11 Zone 1)

– Typ A und Typ B Dissection

– Aneurysm Aortic Arch

– TAAA

– Aortobronchial Fistula

• 84% Emergency

• 13.1% Stroke

• 2.7% Paraplegia

• n = 393

• 4.9% stroke, if LSA covered

• 0% stroke, if LSA-Plug before Arch

maneuver or Debranching before

Stenting

Cervical Debranching:

n=193 (2010-2015)

Surgery n additional

Carotid Subclavian

Bypass

139 CCA Interposition (6)

Subclavian

Transposition

26

Carotid Carotid Bypass 14

Vertebral Transposition 11

Subclavian Subclavian 4

Indications

TEVAR (including Ascendant Aorta &

Aortic Arch)

139

Stenosis/Occlusion (Steal or Ischaemia) 14

Ascendens / Arch 8

Subclavian Aneurysm 3

Kommerell Diverticula / Lusorian Artery 2

Trauma 2

Rec. TIA/CVA 1

Complications

Complications n %

Bleeding postop 14 7

Chylus fistula 4 2

Bypass Infection 3 1.5

Horner´s Syndrome 7 3.5

Recurrent Nerve palsy 6 3

Cerebral ischemia 4 2

Death 17 9

Horner´s Syndrome

Vertebral

Transposition

4/11 36%

Subclavian

Transposition

2/26 7.5%

Carotid Subclavian

Bypass

1/139 0.5%

Paresis Recurrent Laryngeal Nerve

Subclavian

Transposition

3/26 11.5%

Vertebral

Transposition

1/11 9%

Carotid Subclavian

Bypass

2/139 1%

Lessons learned:Technical Notes

In case of affection of

common carotid artery:

Common carotid artery

interposition graft

and carotid-subclavian

bypass

.

Lessons learned:Technical Note

for easy wire / graft

access to the

proximal CCA:

Avoid sharp proximal

angle Horizontal

Course of Subclavian-

Carotid Bypass (8 mm

Dacron)

Technical Note

To avoid bleeding:

Separate Open

Debranching from

TEVAR procedure

Reviews on Cervical Debranching…

Kotelis et al. Total vs hemi-aortic arch transposition for hybrid aortic arch repair. J Vasc Surg.

2011 Oct; 54(4):1182

Cao et al. Systematic review of clinical outcomes in hybrid procedures for aortic arch dissections

and other arch diseases. J Thorac Cardiovasc Surg. 2012 Dec; 144(6):1286

Antoniou et al. Hybrid treatment of complex aortic arch disease with supra-aortic debranching

and endovascular stent graft repair. Eur J Vasc Endovasc Surg. 2010 Jun; 39(6):683

Different Diseases,

Different Techniques,

Different Vessels…..

In hospital mortality 6.5-15%

Paraplegia 0-1.5%

Stroke 3.7-12%

• Cervical Debranching: Portfolio for Aortic

Arch and thoracic Aorta Treatment

• Local Complication rates low in High Risk

Patients

• Indications have changed: „Service

Procedure“

• Different Techniques are associated with

different Complications

CONCLUSIONS

Forward. Together.

European Society for Vascular SurgerySpecialists in Vascular HealthCare

Join us in Lyon, France!Sept 19-22 2017

Cervical Debranching for Endovascular Arch

Repair:

Results, Tips and Tricks

ES Debus, Ch Vermeulen, A Larena, S Wipper, N Tsilimparis, T Kölbel

Department for Vascular Medicine

German Aortic Center Hamburg

University Heart Center Hamburg, Germany